Healthcare Provider Details

I. General information

NPI: 1184025744
Provider Name (Legal Business Name): LILIANA ROLLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 NORTHWEST LN SE STE A
LACEY WA
98503-6908
US

IV. Provider business mailing address

1450 NORTHWEST LN SE STE A
LACEY WA
98503-6908
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4460
  • Fax: 360-491-3090
Mailing address:
  • Phone: 360-491-4460
  • Fax: 360-491-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60582317
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: